A novel device with pedicular anchorage provides better biomechanical properties than balloon kyphoplasty for the treatment of vertebral compression fractures.

PURPOSE: To compare the biomechanical behavior of vertebrae with vertebral compression fractures (VCF) treated by a novel system with pedicular anchorage (dowelplasty) versus balloon kyphoplasty. METHODS: Four cadaveric spines (T12-L5) were harvested, cleaned from soft tissues, and separated into vertebrae. Axial compressive loads were applied to each vertebra until a VCF was generated. Half of the vertebrae (n = 11) were instrumented using the "dowelplasty" system, consisting of a hollow titanium dowel anchored into the pedicle, through which a cannulated titanium nail is inserted and locked and through which cement is injected. The other half (n = 11) were instrumented using balloon kyphoplasty. Axial compressive loads were re-applied to each vertebra until fracture. Fracture load and fracture energy were calculated from load-displacement data for the pre- and post-treatment states. RESULTS: Compared to balloon kyphoplasty, dowelplasty granted greater net change in fracture load (373N; 95%CI,-331-1076N) and fracture energy (755Nmm; 95%CI,-563-2072Nmm). A sensitivity analysis was performed without L4 and L5 vertebrae from the dowelplasty group, since the length of the cannulated nails was too short for these vertebrae: compared to balloon kyphoplasty, dowelplasty granted an even greater net change in fracture load (680N; 95%CI,-96-1457N) and fracture energy (1274Nmm; 95%CI,-233-2781Nmm). CONCLUSION: Treating VCFs with dowelplasty grants increased fracture load and fracture energy compared to the pre-treatment state. Furthermore, dowelplasty grants greater improvement in fracture load and fracture energy compared to balloon kyphoplasty, which suggests that dowelplasty may be a good alternative for the treatment of VCF. LEVEL OF EVIDENCE: level IV.

Team management in complex posterior spinal surgery allows blood loss limitation.

PURPOSE: The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding. METHODS: We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( -)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL. RESULTS: One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p < 0.05; OR 3.38) and performing a PSO (p < 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p < 0.05; OR 2.48) and higher BMI (p < 0.05; OR 2.15) were associated to a more significant post-operative HBL. CONCLUSION: With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.

Computed Tomography Intraoperative Navigation in Spinal Surgery: Assessment of Patient Radiation Exposure in Current Practices.

BACKGROUND: Patient radiation exposure associated with the use of computed tomography (CT) navigation during spinal surgeries was widely compared with other intraoperative imaging techniques. The aim of this study is to explore the use of navigation with regard to current spinal surgery practices and the technical limitations of such imaging systems. METHODS: Dosimetric data from 101 patients who underwent intraoperative, CT-navigated spine surgery were retrospectively collected. The study population was divided into 3 groups according to the primary surgical indication. The number of CT image acquisitions per patient, the field length, and the time of exposure per acquisition during a single surgery were compared as well as the radiation dose emitted to patients. RESULTS: Dose-length products (DLP) per acquisition were 678.52, 656.8, and 649.36 mGy·cm with no significant difference for spinal deformity (SD), degenerative disease (DD), and vertebral fracture (VF) procedures, respectively. Analyzing the number of CT image acquisitions per patient revealed that repeated intraoperative scans were often performed for patients who were suffering from an SD due to technical limitations of the navigation. As a consequence, the cumulative dose was higher in the SD group (DLP total = 1175 mGy·cm) than in the DD (DLP total = 762.74 mGy·cm) and VF (DLP total = 649.36 mGy·cm) groups. CONCLUSIONS: CT navigation is an efficient intraoperative imaging technique that reduces the rate of surgical complications, but its technical limitations lead to an increased risk of patient radiation exposure, especially for complex surgeries where multiple scanning acquisitions are needed. CLINICAL RELEVANCE: To avoid patient's overexposure, spine surgeons should minimize the number of intraoperative acquisitions while considering the complexity of the surgery and the limitations of the guidance system. The use of dual guidance systems has also to be considered according to the benefit-risk balance between patient's outcomes and radiation dose exposure.

Original Surgical Treatment and Long-term Follow-up for Chronic Inflammatory Demyelinating Polyradiculoneuropathy Causing a Compressive Cervical Myelopathy: Review of the Literature.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic relapsing disease of unknown aetiology. The diagnosis of this disease is still very complicated. The treatment is medical but, in some cases, a surgical decompression might be required. In rare cases it develops a radicular hypertrophy that can cause a cervical myelopathy; this pathology should be put in differential diagnosis with neurofibromatosis 1 and CharcotMarie-Tooth (CMT) syndromes. The cases of CIDP cervical myelopathy reported in the literature are rare and even more rarely a surgical decompression was described. Here we report a first and unique case of CIDP cervical myelopathy treated with an open-door laminoplasty technique with 10-year postoperative follow-up (FU). The surgical decompression revealed to be effective in stopping the progression of myelopathy without destabilizing the spine. The patient that before surgery presented a severe tetraparesis could return to walk and gain back his self-care autonomy. At 10-year FU he did not complain of neck pain and did not develop a cervical kyphosis. In case of cervical myelopathy caused by radicular hypertrophy, CIDP should be kept in mind in the differential diagnosis and an open-door laminoplasty is indicated to stop myelopathy progression.